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San Joaquin County i <br />Environmental Health Department u V ��-.-. SITE <br />p <br />�i 304 East Weber Avenue, 3rd Floor, Stockton, CA 91;0;! j �( 2007 MITIGATION <br />17 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />UNIT IV <br />Well Permit Application <br />Fr,�Vlf��?N �dT HE i <br />pFq�./E1/iC <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. �9F3iD•Z3 <br />/�. y/o • y9 Assessors <br />WELL Location Harlan Road (APN 4A@9--2tt)- Cross Street East Louise Ave. City Lathrop Zip 95330 Parcel#92&-2 <br />PROPERTY <br />Owner Richland Crossroads, LP Address 2220 Douglas Blvd., Suite 290 City Roseville Zip 95661 Phone#_(916) 782-3330 <br />C-57 Contractor Cascade Drilling Inc. Address 3632 Omec Circle City Rancho Cordova Zip 95742 Lic# C57-717510 Phone#_(916) 638-1169 <br />Consultant / Sub Cntr SECOR International Inc. Address 3017 Kilgore Rd., Suite 100 City Rancho Cordova Lic# 654498 Phone#_(916) 861-0400 <br />GIS Coordinates: 447. 31.8107- , 4-4: -/Z/. ,tfy�L , Township <br />Range Secti <br />WORK TO BE PERFORMED: <br />[x] NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) [x] DESTRUCTION (choose type below) _ <br />0 SOIL BORING # [X] OVER -BORE. DIAMETER 10" <br />[X] WELL # MW -14 0 PRESSURE GROUT <br />0 *Otherp GROUT SPECIFICATIONS <br />COMMENTS: O �Z /�K�/ •� D�/Ej�G E' �E5T.2UG%10/U w� /D f /LE' //N�11�L� �Q.►.�e <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />[X] MONITORING [X] HOLLOW STEM DIA. OF BOREHOLE 10" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2" <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SCH 40 TYPE OF CASING: 0 STEEL [X] PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 3 ft bgs TREMIE TYPE TO BE USED: [X] AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes [X] No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Portland Neat Cement <br />0 OTHER:_o OTHER APPROX. BORING DEPTH 21 ft. bgs. [X] BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinance , Rules and Regulations, a all applicable California State Laws. <br />Signed x Title/Company Proiect Geologist / SECOR International Inc. <br />Print Name Cohn O'Donnell Date 3/12/2007 <br />SITE MAP IN UNIT IV FILE, ADDRESS:_ <br />WORK PLAN DATED: /4 <br />Application Accepted By_ <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />DEPARTMENT USE ONLY <br />165 a a S .Z <br />1--05 <br />Date <br />nal Inspection By <br />!!t22 135,2& LUf - 1D <br />/— /D - Zo0 6 a �y <br />rs Ar <br />..ea a6 6 <br />,-Ii A-L&�ti <br />ACCOUNTING ONLY: AID# FAC# \ <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PE VICE REQUES <br />INVOICE <br />X50 <br />�i �fl•- <br />/z <br />- sR# ot)�U0,v� <br />C-57_ WC v" -WAIVER_ C-57 Letter of Authorization to sign permit ✓ mrr t� ocd <br />EHD 29-02-001 #CC4--j <br />6/22/04 <br />